"Doctor ... Always Do the Right Thing"

By Marco Lopez, DC, CCEP

So says "Da Mayor" in the iconic Spike Lee movie. As a fresh grad questioning in-network versus out-of-network, it struck me that some doctors have explicitly skirted the issue, while others have argued adamantly for the latter and "sticking it to the man." Next question: Will Grandma benefit from your expertise? Worse still ...

Medicaid? After five years, I still can't figure that out. But with the Accountable Care Act looming, the profession must face a changing health care market, new paradigms of care reflecting value-based systems, and significant increases of insured patients. That leads us to more questions – and potential opportunities.

Keep in mind as we enter this discussion that I previously wrote about the challenges of parity in terms of reimbursement, and questioned the profession's collective perpetuation of unfair and constraining reimbursement practices. We are competing to "treat" the 8 percent that utilizes our services, while the rewards of caring for the 92 percent slip through our fingers. We need to do something fast.

The Medicaid Opportunity

Kaiser reports that Medicaid is the largest provider of health care in the country, with many more en route. You're a numbers guy? Me too. That's 60 million people or about 20 percent of the good 'ol US of A. I had avoided Medicaid patients because of the perceived stigma – not to mention the insulting reimbursement rates. Don't feel bad. Many doctors avoid Medicaid. A recent article brought this to my attention.

The author, Dr. Marc Tunzi, wrestles with this dilemma in a schizophrenic fashion. His conclusion: Physician success is a societal sequela. As such, public service is a necessary extension of the social contract enjoyed by physicians. Granted, Dr. Tunzi addresses the other side, but our profession has brawled for "physician status." Some docs travel abroad on noble missions to bring chiropractic to the less fortunate of the world, even while some 56 million necessitous, insolvent, hardscrabble folk subsist stateside.

Medicaid will cover more backs – an estimated 30 million more. The cost of treating back pain has not improved. Many of the 80 percenters are straightforward cases. In contrast, the few cases seen to date are caseworthy. After all, if you have insurance that no one accepts, are you covered? Many of our neighbors are neglected or written off. The biomedical approach for treating back pain is not working and now it will not work for more people. These patients will need guidance. We can help.

If this sappy plea does not stir your pot, consider a pragmatic reflection. Accountable Care Act mandates increased Medicaid coverage for individuals earning up to $15K/yr, $20K for a family of three or $24K for a family of four. (On a side note, citizens earning up to four times the poverty levels [$46K] are eligible for real-time tax credits that can be applied to reduce monthly insurance premiums.) The law aims to capture half of the uninsured or some 30 million people; that means 30 million less cash patients!

What does that matter, you say; they are in the 92 percent bracket we don't treat. That may be true, but Medicaid reimbursements are expected to rise to Medicare rates, at least for primary care physicians and a select few. (Granted, the life of this incentive is unclear.)

On a brighter note, 2014 brings increased Medicare reimbursements. Now imagine if Medicaid reimbursed at Medicare rates. Would that change your tune?

Should We Take a Short-Term Loss for a Long-Term Gain?

So, should our profession collectively take it on the chin? Would you take one for team chiropractic? Could eating the short-term loss set the stage for long-term gains in governmental reimbursement parity? Should we parlay our participation in federal programs into a broader insurance reimbursement package as primary spine care providers? We certainly bill the hell out of private insurance and personal injury. Yet how can we ask for parity on services we don't provide? You don't have to be an Ivy League health economist to deduce the hypocrisy of that premise.

Hold up, you say: Citizens can opt out of insurance, pay the federal penalty and front cash for services they want. At least 26 million will. This option is better for some, including those not eligible for Medicaid or other "Obamacare" edicts. That works until penalties exceed insurance premiums. "Yikes! you say. "I work very hard taking care of my patients. What do you want from me?" Refer back to Dr. Tunzi and heed "Da Mayor."

Before branding me a socialist, mull over the argument. This logic may be state specific, but in terms of federally funded programs, broadening your practice base may be worth revisiting. Don't open the floodgates; but what's a few drips? Hijacking William Zissner's unwittingly appropriate words, "The insurance industry is trying to rewrite its policies in less disastrous English what redress will be ours when disaster strikes."

Cost-benefit analyses are looming. Federal reduction of blanket Medicare / Medicaid payments for surgical and invasive procedures has started. The Accountable Care Act is not going away. Blame what you will; as for me, I am a survivalist following "Da Mayor's" counsel. N.J. Spine Doc over and out.

Dr. Marco Lopez, a graduate of Palmer College of Chiropractic Florida, completed undergraduate study (pre-med) at Boston University. He practices in the New York Metro area, including northern N.J., and can be contacted with questions and comments at www.njspinedoc.com.

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